Medicaid Waiver Services Documentation Requirements

Documentation Requirements for Day Habilitation

Functional Analysis

Develop a functional analysis of the individuals capabilities with in the first month and annually.

Develop an ISP that includes the following:

The individuals interest

Choices

Measurable outcomes

Submit quarterly reports to the individual, family/guardian, and Service Coordinator on the programming and support provided to achieve the outcomes in the ISP.

In-Home Day Habilitation

Day Habilitation provider must provide written documentation that in-home service are necessitated by the individual’s medical or safety needs.

The Day Habilitation provider are responsible for developing the ISP goals and activities. The plan should include transitioning the individual to the community to the extent possible.

Documentation Requirement for Prevocational services

Prepare Vocational Assessments

Vocational assessment within the 90 days of intake and annually. The vocational assessment must include the following:

Employment-related strengths and weaknesses

Available natural/community supports

Individual concerns and preferences

Accommodations and supports that may be required on the job.

Develop an ISP

The ISP includes the following:

The person interest

Specific measurable outcomes for the development of vocational skills that are consistent with the goals

Activities shall be functional.

File Quarterly Reports

Submit quarterly reports, no later that the 15th day of January, April, July, and October. The quarterly reports will include the following:

Name of the person

Community inclusion opportunities

Volunteer activities

Prevocational facility and non-facility-based activities

Progress to achieving outcomes from IHP.

Documentation Requirements for Supported Employment

Complete a comprehensive vocational assessment.

The vocational assessment includes the following:

Employment-related strengths and weakness

Available family and community supports

Personal concerns

Accommodations and supports that may be required on the job

If specific job or entrepreneurial efforts has been targeted the assessment may include:

Individualized training needs

Anticipated level of interventions that will be required by the job coach.

Type of integrated work environment

Supports that are needed to improve potential for employment.

Provide written justification ten business day prior to the prior authorization expires to request an extension.

Maintain service records that accurately link the services billed to the ISP/POC.

The documentation includes:

Individual’s name

Staff person’s name

Date(s) of activities

Start and end times of activities

Purpose of activities

Location of activities

Occurrences or behaviors that impede the progress of the group or individual participants

Any unusual circumstances or events that impact the stability of the group or individuals participant

Any incidents

Actions take to address behaviors or unusual circumstances

Submit quarterly reports that include the following:

Individual’s name

Confirmation that wages exceed minimum wage

Average hours a week worked by each person

Hours of activities for each person if not engage in employment

Aggregate calculation of wages earned, hours worked and hours of activities for person not engaged in employment.

Documentation Requirements for Supported Living and Residential Habilitation

Develop a functional analysis of the individual’s capabilities with the first month.

Develop a support plan with measurable outcomes using the functional analysis, ISP/POC, and other information to develop and maintain skills to remain in the community while maintaining the individual’s health and safety.

Maintain a participants attendance roster on a daily basis.

Maintain weekly progress notes or more frequently.

Progress notes include:

Progress in meeting each goal in the ISP assigned to the supported living and residential habilitation provider.

A list of all community activities and the individual’s response to each activity.

Any health events, side effects to medication, change in health status, behavioral event, use of restrictive procedures or unusual incidents.

Each visitor the person receives, special events, and any situation or event requiring follow up.

Quarterly reports that include the activities and support provided to help the individual achieve his/her identified outcomes and progress to date.

Maintain current financial records of expenditures.

Documentation Requirements for Respite

Provider must maintain documentation the following information:

Date and amount of time the service is delivered

Record the activities engaged in

Individual’s response to those activities

Unusual events or circumstance involving the individual’s health and welfare while respite services were delivered.

Documentation Requirements for Host Homes

Develop a functional analysis of the individual’s capabilities with the first month.

Develop a support plan with measurable outcomes using the functional analysis, ISP/POC, and other information to develop and maintain skills to remain in the community while maintaining the individual’s health and safety.

Maintain weekly progress notes or more frequently.

Progress notes will include the progress in meeting each goal in the ISP assigned to the Host Home provider.

Person-Centered Thinking

Person-centered thinking is a philosophy behind service provision that supports positive control and self-direction of people’s own lives. DDS is working to implement this through training sessions and other agency wide initiatives.

Employment First Initiative

Under the Employment First philosophy, competitive, integrated employment is the first and overwhelmingly preferred option for working-age youth and adults with disabilities.